1
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Bolk KG, Wise SK. Biologic Therapies across Nasal Polyp Subtypes. J Pers Med 2024; 14:432. [PMID: 38673059 PMCID: PMC11051580 DOI: 10.3390/jpm14040432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Chronic rhinosinusitis with nasal polyposis is a common inflammatory condition, with subtypes like aspirin-exacerbated respiratory disease, allergic fungal rhinosinusitis, and central compartment atopic disease sharing a common type 2 inflammatory pathway. Respiratory biologic therapies have been developed that target type 2 inflammation. In this article, we discuss the use of respiratory biologic therapies for nasal polyposis in general, as well as within the various subtypes of nasal polyps. Further, we discuss future roles of novel biologic therapies targeting type 2 inflammation in nasal polyposis.
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Affiliation(s)
| | - Sarah K. Wise
- Department of Otolaryngology—Head and Neck Surgery, Emory University Hospital Midtown, Emory University, Atlanta, GA 30308, USA
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2
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Bolk KG, Edwards TS, Wise SK, DelGaudio JM. Allergy and Asthma Prevalence and Management Across Nasal Polyp Subtypes. Otolaryngol Clin North Am 2024; 57:253-263. [PMID: 37827956 DOI: 10.1016/j.otc.2023.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Allergy and asthma prevalence vary across different subsets of chronic rhinosinusitis with nasal polyposis. In this article, the authors investigate the management of allergy and asthma within populations of patients with aspirin-exacerbated respiratory disease, allergic fungal rhinosinusitis, and central compartment atopic disease. Topical steroids, nasal rinses, and endoscopic sinus surgery are frequently employed in the management of nasal polyposis. Further, other causes of upper and lower airway inflammation like allergy and asthma should be considered in the overall treatment plan in order to optimize outcomes.
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Affiliation(s)
- Kody G Bolk
- Department of Otolaryngology-Head and Neck Surgery, Emory University Hospital Midtown, 550 Peachtree Street NE, MOT Suite 1135, Atlanta, GA 30308, USA.
| | - Thomas S Edwards
- Department of Otolaryngology-Head and Neck Surgery, Emory University Hospital Midtown, 550 Peachtree Street NE, MOT Suite 1135, Atlanta, GA 30308, USA
| | - Sarah K Wise
- Department of Otolaryngology-Head and Neck Surgery, Emory University Hospital Midtown, 550 Peachtree Street NE, MOT Suite 1135, Atlanta, GA 30308, USA
| | - John M DelGaudio
- Department of Otolaryngology-Head and Neck Surgery, Emory University Hospital Midtown, 550 Peachtree Street NE, MOT Suite 1135, Atlanta, GA 30308, USA
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3
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Oliveira M, Oliveira D, Lisboa C, Boechat JL, Delgado L. Clinical Manifestations of Human Exposure to Fungi. J Fungi (Basel) 2023; 9:jof9030381. [PMID: 36983549 PMCID: PMC10052331 DOI: 10.3390/jof9030381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Biological particles, along with inorganic gaseous and particulate pollutants, constitute an ever-present component of the atmosphere and surfaces. Among these particles are fungal species colonizing almost all ecosystems, including the human body. Although inoffensive to most people, fungi can be responsible for several health problems, such as allergic fungal diseases and fungal infections. Worldwide fungal disease incidence is increasing, with new emerging fungal diseases appearing yearly. Reasons for this increase are the expansion of life expectancy, the number of immunocompromised patients (immunosuppressive treatments for transplantation, autoimmune diseases, and immunodeficiency diseases), the number of uncontrolled underlying conditions (e.g., diabetes mellitus), and the misusage of medication (e.g., corticosteroids and broad-spectrum antibiotics). Managing fungal diseases is challenging; only four classes of antifungal drugs are available, resistance to these drugs is increasing, and no vaccines have been approved. The present work reviews the implications of fungal particles in human health from allergic diseases (i.e., allergic bronchopulmonary aspergillosis, severe asthma with fungal sensitization, thunderstorm asthma, allergic fungal rhinosinusitis, and occupational lung diseases) to infections (i.e., superficial, subcutaneous, and systemic infections). Topics such as the etiological agent, risk factors, clinical manifestations, diagnosis, and treatment will be revised to improve the knowledge of this growing health concern.
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Affiliation(s)
- Manuela Oliveira
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal
- Ipatimup-Instituto de Patologia e Imunologia Molecular da Universidade do Porto, Rua Júlio Amaral de Carvalho 45, 4200-135 Porto, Portugal
| | - Diana Oliveira
- CRN-Unidade de Reabilitação AVC, Centro de Reabilitação do Norte, Centro Hospitalar de Vila Nova de Gaia/Espinho, Avenida dos Sanatórios 127, 4405-565 Vila Nova de Gaia, Portugal
| | - Carmen Lisboa
- Serviço de Microbiologia, Departamento de Patologia, Faculdade de Medicina do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- Serviço de Dermatologia, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- CINTESIS@RISE-Centro de Investigação em Tecnologias e Serviços de Saúde, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - José Laerte Boechat
- CINTESIS@RISE-Centro de Investigação em Tecnologias e Serviços de Saúde, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Luís Delgado
- CINTESIS@RISE-Centro de Investigação em Tecnologias e Serviços de Saúde, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- Laboratório de Imunologia, Serviço de Patologia Clínica, Centro Hospitalar e Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
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4
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Luong AU, Chua A, Alim BM, Olsson P, Javer A. Allergic Fungal Rhinosinusitis: The Role and Expectations of Biologics. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3156-3162. [PMID: 36028212 DOI: 10.1016/j.jaip.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/09/2022] [Accepted: 08/16/2022] [Indexed: 12/14/2022]
Abstract
Allergic fungal rhinosinusitis (AFRS) is a noninvasive subtype of chronic rhinosinusitis with nasal polyps (CRSwNP) that usually develops in immunocompetent atopic individuals and is more common in geographic regions characterized by warm temperatures and high humidity, conducive to higher environmental fungal presence. Allergic fungal rhinosinusitis usually presents with unique computed tomography findings and significant polyp burden, yet patients often report minimal sinus symptoms. Patients with AFRS often have extremely elevated serum total and fungal-specific IgE levels. Treatment almost always requires surgery, in which adjuvant medical therapy is critical to success. However, until recently the choice of adjuvant therapy has consisted primarily of either oral and/or topical steroids. Although oral corticosteroids decrease recurrence after surgery, data for the effectiveness of other adjunctive pharmacologic agents, including topical and oral antifungal agents and immunotherapy, have remained unclear and hence are not recommended in recent guidelines including the International Consensus of Allergy and Rhinology. Three biologics, omalizumab, dupilumab, and mepolizumab, have recently been approved for treating CRSwNP in general, but clinical trials to date with these biologics did not involve AFRS patients. Recently published case reports and smaller prospective studies have shown good efficacy of these biologics on the AFRS subgroup of patients. This article provides an overview of the understanding of the pathophysiology of AFRS, implications of this understanding on the possible role of biologics, and clinical reports on the use of biologics in treating AFRS. Because biologics are indicated for treating CRSwNP, follow up real-world evidence studies are needed for AFRS.
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Affiliation(s)
- Amber U Luong
- McGovern Medical School of the University of Texas Health Science Center at Houston, Houston, Texas.
| | - Andy Chua
- McGovern Medical School of the University of Texas Health Science Center at Houston, Houston, Texas
| | - Bader M Alim
- Division of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, Canada
| | - Petter Olsson
- Novartis AB, Kista, Sweden; Division of Ear, Nose, and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Amin Javer
- St Paul's Sinus Centre, University of British Columbia, Vancouver, Canada
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Medikeri G, Javer A. Optimal Management of Allergic Fungal Rhinosinusitis. J Asthma Allergy 2020; 13:323-332. [PMID: 32982320 PMCID: PMC7494399 DOI: 10.2147/jaa.s217658] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/13/2020] [Indexed: 01/02/2023] Open
Abstract
Introduction Allergic fungal rhinosinusitis (AFRS) is a chronic disorder with significant morbidity and a high recurrence rate needing long-term follow-up. Even after its first description many decades ago, there is still considerable uncertainty about the management of this condition. Description In this chapter, we breakdown the topic “Optimal management of allergic fungal rhinosinusitis” into sub-headings in order to discuss the latest research and available literature under each topic in great detail. Every attempt has been made to incorporate the highest level of evidence that was available at the time of writing. Summary Pre-operative diagnosis and further management prior to surgery is important. Steroids help in reducing inflammation and help improve the surgical field. Surgery remains the mainstay in the management of this condition along with long-term medical management. Oral steroids are reserved for acute flare-ups in the background of associated lung concerns. Oral and topical antifungal agents have no role in the control of the disease. Biological agents are being prescribed predominantly by respiratory physician colleagues, mainly for the control of the chest-related issues rather than for sinus disease. Immunotherapy as an adjunct with surgery is promising. Conclusion AFRS is a disease with many variables and a wide range of symptomatic presentation. It takes a keen clinician to identify the disease and subsequently manage the condition. Treatment involves long-term follow-up with early detection of recurrence or flare-ups. Any of the mentioned modalities of management may be employed to effectively control the condition, and treatment protocols will have to be tailor-made to suit each individual patient. Various medications and drugs such as Manuka honey, antimicrobial photodynamic therapy, hydrogen peroxide and betadine rinses appear to be promising. More robust studies need to be undertaken to ascertain their routine use in clinical practice.
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Affiliation(s)
| | - Amin Javer
- Rhinology & Skull Base Surgery, St. Paul's Sinus Center, Vancouver, BC, Canada
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Tyler MA, Luong AU. Current Concepts in the Management of Allergic Fungal Rhinosinusitis. Immunol Allergy Clin North Am 2020; 40:345-359. [PMID: 32278456 DOI: 10.1016/j.iac.2019.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Allergic fungal rhinosinusitis (AFRS) represents a subtype of chronic rhinosinusitis with nasal polyposis that exhibits a unique, often striking clinical presentation. Since its initial description more than a quarter century ago, a more sophisticated understanding of the pathophysiology of AFRS has been achieved and significant advancements in improving clinical outcomes made. This review focuses on the latest developments involving the pathophysiology and clinical management of this fascinating disease.
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Affiliation(s)
- Matthew A Tyler
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota Medical School, 516 Delaware Street Southeast, # 8A, Minneapolis, MN 55455, USA
| | - Amber U Luong
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Texas Sinus Institute, 6431 Fannin Street, MSB 5.036, Houston, TX 77030, USA; Center for Immunology and Autoimmune Diseases, Institute of Molecular Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.
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Dykewicz MS, Rodrigues JM, Slavin RG. Allergic fungal rhinosinusitis. J Allergy Clin Immunol 2019; 142:341-351. [PMID: 30080526 DOI: 10.1016/j.jaci.2018.06.023] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 06/26/2018] [Accepted: 06/26/2018] [Indexed: 02/06/2023]
Abstract
Allergic fungal rhinosinusitis (AFRS) is a subset of chronic rhinosinusitis with nasal polyps (CRSwNP) characterized by antifungal IgE sensitivity, eosinophil-rich mucus (ie, allergic mucin), and characteristic computed tomographic and magnetic resonance imaging findings in paranasal sinuses. AFRS develops in immunocompetent patients, with occurrence influenced by climate, geography, and several identified host factors. Molecular pathways and immune responses driving AFRS are still being delineated, but prominent adaptive and more recently recognized innate type 2 immune responses are important, many similar to those established in patients with other forms of CRSwNP. It is unclear whether AFRS represents merely a more extreme expression of pathways important in patients with CRSwNP or whether there are other disordered immune responses that would define a distinct endotype or endotypes. Although AFRS and allergic bronchopulmonary aspergillosis share some analogous immune mechanisms, the 2 conditions do not occur commonly in the same patient. Treatment of AFRS almost always requires surgical debridement of the involved sinuses. Oral corticosteroids decrease recurrence after surgery, but other adjunctive pharmacologic agents, including topical and oral antifungal agents, do not have a firm evidence basis for use. There is good rationale for use of biologic agents that target eosinophilic inflammation or other type 2 responses, but studies in patients with AFRS are required.
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Affiliation(s)
- Mark S Dykewicz
- Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, Mo.
| | - Jonathan M Rodrigues
- Allergy and Immunology, Sanford Health, and the Department of Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Bismarck, ND
| | - Raymond G Slavin
- Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, Mo
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Tyler MA, Luong AU. Current understanding of allergic fungal rhinosinusitis. World J Otorhinolaryngol Head Neck Surg 2018; 4:179-185. [PMID: 30506049 PMCID: PMC6251961 DOI: 10.1016/j.wjorl.2018.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 01/12/2023] Open
Abstract
Studying the pathophysiology of allergic fungal rhinosinusitis (AFRS) has proved challenging. While this clinical entity is easily distinguishable based on the clinical criteria set forth by Bent and Kuhn twenty-five years ago, studies examining type 2 inflammatory profiles in AFRS can make it seem more alike other CRS subtypes than it is different. Still, evolving research seems to clearly delineate this subtype from others in CRS. This review will critically evaluate the evolution of research examining the pathophysiology of AFRS and will conclude with a summary of the special considerations in the management of this fascinating disease.
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Affiliation(s)
- Matthew A Tyler
- McGovern Medical School at the University of Texas Health Science Center, Department of Otorhinolaryngology-Head & Neck Surgery, Houston, TX 77030, USA
| | - Amber U Luong
- McGovern Medical School at the University of Texas Health Science Center, Department of Otorhinolaryngology-Head & Neck Surgery, Houston, TX 77030, USA.,McGovern Medical School at the University of Texas Health Science Center, Center for Immunology and Autoimmune Diseases, Institute of Molecular Medicine, Houston, TX 77030, USA
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Mullings WP, Al-Salman R, Javer AR. Managing Allergic Fungal Rhinosinusitis. CURRENT OTORHINOLARYNGOLOGY REPORTS 2018. [DOI: 10.1007/s40136-018-0206-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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10
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Currens J, Hutcheson PS, Slavin RG, Citardi MJ. Primary Paranasal Aspergillus Granuloma: Case Report and Review of the Literature. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240201600308] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Primary paranasal aspergillus granuloma (PPAG) is a slowly progressive chronic infection of the sinus extending beyond the confines of the sinus. It has been reported only in patients from the Sudan and India. Microscopically, it differs from chronic invasive fungal sinusitis in that there are pseudotubercles containing giant cells, histiocytes, lymphocytes, plasma cells, newly formed capillaries, eosinophils, and Aspergillus fungal elements. Conclusion We describe the first case of PPAG in the United States in an immunocompetent nonatopic woman who had never left Missouri.
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Affiliation(s)
- John Currens
- Departments of Otolaryngology–Head and Neck Surgery and Division of Allergy and Immunology, St. Louis University School of Medicine, St. Louis, Missouri
| | - Patricia S. Hutcheson
- Departments of Internal Medicine, Division of Allergy and Immunology, St. Louis University School of Medicine, St. Louis, Missouri
| | - Raymond G. Slavin
- Departments of Internal Medicine, Division of Allergy and Immunology, St. Louis University School of Medicine, St. Louis, Missouri
| | - Martin J. Citardi
- Department of Otolaryngology and Communicative Disorders, Cleveland Clinic Foundation, Cleveland, Ohio
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Halderman AA, Tully LJ. The Role of Allergy in Chronic Rhinosinusitis. Otolaryngol Clin North Am 2017; 50:1077-1090. [DOI: 10.1016/j.otc.2017.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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12
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Chakrabarti A, Kaur H. Allergic Aspergillus Rhinosinusitis. J Fungi (Basel) 2016; 2:E32. [PMID: 29376948 PMCID: PMC5715928 DOI: 10.3390/jof2040032] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/29/2016] [Accepted: 12/01/2016] [Indexed: 12/19/2022] Open
Abstract
Allergic fungal rhinosinusitis (AFRS) is a unique variety of chronic polypoid rhinosinusitis usually in atopic individuals, characterized by presence of eosinophilic mucin and fungal hyphae in paranasal sinuses without invasion into surrounding mucosa. It has emerged as an important disease involving a large population across the world with geographic variation in incidence and epidemiology. The disease is surrounded by controversies regarding its definition and etiopathogenesis. A working group on "Fungal Sinusitis" under the International Society for Human and Animal Mycology (ISHAM) addressed some of those issues, but many questions remain unanswered. The descriptions of "eosinophilic fungal rhinosinusitis" (EFRS), "eosinophilic mucin rhinosinusitis" (EMRS) and mucosal invasion by hyphae in few patients have increased the problem to delineate the disease. Various hypotheses exist for etiopathogenesis of AFRS with considerable overlap, though recent extensive studies have made certain in depth understanding. The diagnosis of AFRS is a multi-disciplinary approach including the imaging, histopathology, mycology and immunological investigations. Though there is no uniform management protocol for AFRS, surgical clearing of the sinuses with steroid therapy are commonly practiced. The role of antifungal agents, leukotriene antagonists and immunomodulators is still questionable. The present review covers the controversies, recent advances in pathogenesis, diagnosis, and management of AFRS.
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Affiliation(s)
- Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India.
| | - Harsimran Kaur
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India.
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Hoyt AE, Borish L, Gurrola J, Payne S. Allergic Fungal Rhinosinusitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:599-604. [DOI: 10.1016/j.jaip.2016.03.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 03/02/2016] [Accepted: 03/08/2016] [Indexed: 12/17/2022]
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Rodrigues J, Caruthers C, Azmeh R, Dykewicz MS, Slavin RG, Knutsen AP. The spectrum of allergic fungal diseases of the upper and lower airways. Expert Rev Clin Immunol 2016; 12:531-50. [PMID: 26776889 DOI: 10.1586/1744666x.2016.1142874] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fungi cause a wide spectrum of fungal diseases of the upper and lower airways. There are three main phyla involved in allergic fungal disease: (1) Ascomycota (2) Basidiomycota (3) Zygomycota. Allergic fungal rhinosinusitis (AFRS) causes chronic rhinosinusitis symptoms and is caused predominantly by Aspergillus fumigatus in India and Bipolaris in the United States. The recommended treatment approach for AFRS is surgical intervention and systemic steroids. Allergic bronchopulmonary aspergillosis (APBA) is most commonly diagnosed in patients with asthma or cystic fibrosis. Long term systemic steroids are the mainstay treatment option for ABPA with the addition of an antifungal medication. Fungal sensitization or exposure increases a patient's risk of developing severe asthma and has been termed severe asthma associated with fungal sensitivity (SAFS). Investigating for triggers and causes of a patient's asthma should be sought to decrease worsening progression of the disease.
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Affiliation(s)
| | - Carrie Caruthers
- a Allergy & Immunology , Saint Louis University , St. Louis , MO , USA
| | - Roua Azmeh
- a Allergy & Immunology , Saint Louis University , St. Louis , MO , USA
| | - Mark S Dykewicz
- a Allergy & Immunology , Saint Louis University , St. Louis , MO , USA
| | - Raymond G Slavin
- a Allergy & Immunology , Saint Louis University , St. Louis , MO , USA
| | - Alan P Knutsen
- a Allergy & Immunology , Saint Louis University , St. Louis , MO , USA
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15
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Orphan immunotherapies for allergic diseases. Ann Allergy Asthma Immunol 2016; 116:194-8. [PMID: 26837608 DOI: 10.1016/j.anai.2015.12.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 12/28/2015] [Accepted: 12/30/2015] [Indexed: 01/12/2023]
Abstract
OBJECTIVE As confirmed by systematic reviews and meta-analyses, allergen immunotherapy is clinically effective in the treatment of allergic diseases. In particular, subcutaneous immunotherapy is a pivotal treatment in patients with severe reactions to Hymenoptera venom, whereas subcutaneous immunotherapy and sublingual immunotherapy are indicated in the treatment of allergic rhinitis and asthma by inhalant allergens. Other allergies related to animal dander (other than cat, which is the most studied), such as dog, molds, occupational allergens, and insects, have also been recognized. For these allergens, immunotherapy is poorly studied and often unavailable. Thus, use of the term orphan immunotherapies is appropriate. DATA SOURCES We used MEDLINE to search the medical literature for English-language articles. STUDY SELECTION Randomized, controlled, masked studies for orphan immunotherapies were selected. In the remaining cases, the available reports were described. RESULTS The literature on food desensitization is abundant, but for other orphan allergens, such as mosquito, Argas reflexus, dog, or occupational allergens, there are only a few studies, and most are small studies or case reports. CONCLUSION Orphan immunotherapy is associated with insufficient evidence of efficacy from controlled trials, an erroneous belief of the limited importance of some allergen sources, and the unlikelihood for producers to have a profit in making commercially available extracts (with an expensive process for registration) to be used in few patients. It should be taken into consideration that adequate preparations should be available also for orphan allergens.
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Naha L, Nadour K, Iken M, Lmimouni B. [Allergic fungal rhinosinusitis]. J Mycol Med 2015; 25:293-6. [PMID: 26603100 DOI: 10.1016/j.mycmed.2015.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 09/21/2015] [Accepted: 09/21/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Definition, diagnosis and treatment of allergic fungal sinusitis remain difficult and controversial despite the increasing number of publications. We report a case of an allergic fungal sinusitis with a review of the literature. CLINICAL CASE A 45-year-old man consulted for sinusal polyposis resistant to steroid therapy, clinical examination objectified bilateral nasal polyps and covered with scabs. CT scan of the sinuses disclosed a sinuse filled with a tissue density material containing air with lysis of the left maxillary sinus, hypereosinophilia, the IgE levels were high. Finally, mycological investigation allowed the identification of Aspergillus fumigatus. The patient underwent total ethmoidectomy, histological study found an allergic mucin and inflammatory mucosa with numerous eosinophils. The postoperative course was good and the patient was given oral steroids. The clinical and radiological evolution was favorable without recurrence with a follow-up of three years. DISCUSSION A set of clinical, radiological, histopathological, immunoallergological and mycological criteria is necessary for precise diagnosis and to avoid fungal drift. The treatment is based on endoscopic surgery associated with corticosteroid.
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Affiliation(s)
- L Naha
- Service de parasitologie-mycologie, CeDoc faculté de Médecine et de Pharmacie Mohammed V, hôpital Militaire Mohammed V de Rabat, Rabat, Maroc.
| | - K Nadour
- Service d'ORL et CCF, hôpital Militaire Moulay Ismail de Meknès, Meknès, Maroc
| | - M Iken
- Service de parasitologie-mycologie, CeDoc faculté de Médecine et de Pharmacie Mohammed V, hôpital Militaire Mohammed V de Rabat, Rabat, Maroc
| | - B Lmimouni
- Service de parasitologie-mycologie, CeDoc faculté de Médecine et de Pharmacie Mohammed V, hôpital Militaire Mohammed V de Rabat, Rabat, Maroc
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Abstract
The objective of this article is to review the available studies regarding mold immunotherapy. A literature search was conducted in MEDLINE to identify peer-reviewed articles related to mold immunotherapy using the following keywords: mold, allergy, asthma, and immunotherapy. In addition, references cited within these articles were also reviewed. Articles were selected based on their relevance to the topic. Allergic responses to inhaled mold antigens are a recognized factor in allergic rhinitis and asthma. There are significant problems with respect to the production of relevant allergen material for the diagnosis and treatment of mold allergy with immunotherapy. Mold allergens contain proteases and should not be mixed with other allergens for immunotherapy. Most of the immunotherapy studies focus on two molds, Alternaria and Cladosporium. There is a lack of randomized placebo-controlled trials when evaluating the efficacy of mold immunotherapy with trials only focusing on immunotherapy to Alternaria and Cladosporium. Additional studies are needed regarding mold allergy and immunotherapy focusing on which molds are important for causing allergic disease.
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Affiliation(s)
- Christopher A Coop
- Department of Allergy and Immunology, Wilford Hall Medical Center, 59th Medical Group, 2200 Bergquist Drive Lackland Air Force Base, San Antonio, TX, USA,
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Melzer JM, Driskill BR, Clenney TL, Gessler EM. Sublingual Immunotherapy for Allergic Fungal Sinusitis. Ann Otol Rhinol Laryngol 2015; 124:782-7. [DOI: 10.1177/0003489415583686] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Allergic fungal sinusitis (AFS) is a condition that has an allergic basis caused by exposure to fungi in the sinonasal tract leading to chronic inflammation. Despite standard treatment modalities, which typically include surgery and medical management of allergies, patients still have a high rate of recurrence. Subcutaneous immunotherapy (SCIT) has been used as adjuvant treatment for AFS. Evidence exists to support the use of sublingual immunotherapy (SLIT) as a safe and efficacious method of treating allergies, but no studies have assessed the utility of SLIT in the management of allergic fungal sinusitis. A record review of cases of AFS that are currently or previously treated with sublingual immunotherapy from 2007 to 2011 was performed. Parameters of interest included serum IgE levels, changes in symptoms, Lund-McKay scores, decreased sensitization to fungal allergens associated with AFS, and serum IgE levels. Ten patients with diagnosed AFS were treated with SLIT. No adverse effects related to the use of SLIT therapy were identified. Decreases in subjective complaints, exam findings, Lund-McKay scores, and serum IgE levels were observed. Thus, sublingual immunotherapy appears to be a safe adjunct to the management of AFS that may improve patient outcomes.
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Affiliation(s)
- Jonathan M. Melzer
- Department of Otolaryngology, Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | - Brent R. Driskill
- Department of Otolaryngology, Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | - Timothy L. Clenney
- Department of Otolaryngology, Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | - Eric M. Gessler
- Department of Otolaryngology, Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA
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Peters AT, Spector S, Hsu J, Hamilos DL, Baroody FM, Chandra RK, Grammer LC, Kennedy DW, Cohen NA, Kaliner MA, Wald ER, Karagianis A, Slavin RG. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol 2015; 113:347-85. [PMID: 25256029 DOI: 10.1016/j.anai.2014.07.025] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023]
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Categorization and clinicopathological features of chronic rhinosinusitis with eosinophilic mucin in a korean population. Clin Exp Otorhinolaryngol 2015; 8:39-45. [PMID: 25729494 PMCID: PMC4338090 DOI: 10.3342/ceo.2015.8.1.39] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 09/25/2013] [Accepted: 10/01/2013] [Indexed: 11/18/2022] Open
Abstract
Objectives Chronic rhinosinusitis (CRS) with eosinophilic mucin is relatively rare in Korea. We categorized CRS patients with characteristic eosinophilic mucin into several groups and compared the groups based on their clinicopathological features. Methods In total, 52 CRS patients with eosinophilic mucin were enrolled. Based on the presence or absence of an allergy (A) to a fungus or fungal element (F) in the mucin, the patients were divided into four groups: allergic fungal rhinosinusitis (AFRS, A+F+), AFRS-like sinusitis (A+F-), eosinophilic fungal rhinosinusitis (EFRS, A-F+), and eosinophilic mucin rhinosinusitis (EMRS, A-F-). Clinical and immunological variables were compared between the groups. Results There were 13 patients in the AFRS group, 13 in the EFRS group, and 26 in the EMRS group. No patient was assigned to the AFRS-like sinusitis group. The AFRS group showed a significantly higher association with allergic rhinitis than did the EFRS and EMRS groups. The mean total serum IgE level in the AFRS patients was significantly higher than in the EFRS and EMRS patients. While 7.7% of the patients with AFRS and EFRS were asthmatic, 65.4% of the patients with EMRS had bronchial asthma. In the AFRS and EFRS groups, 31% had bilateral disease, in contrast to 100% of EMRS patients with bilateral disease. The prevalence of high attenuation areas by computed tomography was significantly higher in the AFRS group than in the EMRS group, and the mean Hounsfield unit values of the areas of high attenuation in the AFRS patients were significantly greater than those in the EMRS patients. Conclusion AFRS is believed to be an allergic response to colonizing fungi in atopic individuals. In EFRS, local allergies to fungi may play a role in the pathogenesis of the disease. EMRS is thought to be unconnected with fungal allergies.
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Gan EC, Thamboo A, Rudmik L, Hwang PH, Ferguson BJ, Javer AR. Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence-based review and recommendations. Int Forum Allergy Rhinol 2014; 4:702-15. [PMID: 25044729 DOI: 10.1002/alr.21352] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 04/13/2014] [Accepted: 05/12/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Allergic fungal rhinosinusitis (AFRS) is a subset of polypoid chronic rhinosinusitis that is characterized by the presence of eosinophilic mucin with fungal hyphae within the sinuses and a Type I hypersensitivity to fungi. The treatment of AFRS usually involves surgery in combination with medical therapies to keep the disease in a dormant state. However, what constitutes an optimal medical regimen is still controversial. Hence, the purpose of this article is to provide an evidence-based approach for the medical management of AFRS. METHODS A systemic review of the literature on the medical management of AFRS was performed using Medline, EMBASE, and Cochrane Review Databases up to March 15, 2013. The inclusion criteria were as follows: patients >18 years old; AFRS as defined by Bent and Kuhn; post-sinus surgery; studies with a clearly defined end point to evaluate the effectiveness of medical therapy in postoperative AFRS patients. RESULTS This review identified and assessed 6 medical modalities for AFRS in the literature: oral steroids; topical steroids; oral antifungals; topical antifungals; immunotherapy; and leukotriene modulators. CONCLUSION Based on available evidence in the literature, postoperative systemic and standard topical nasal steroids are recommended in the medical management of AFRS. Nonstandard topical nasal steroids, oral antifungals, and immunotherapy are options in cases of refractory AFRS. No recommendations can be provided for topical antifungals and leukotriene modulators due to insufficient clinical research reported in the literature.
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Affiliation(s)
- Eng Cern Gan
- St Paul's Sinus Centre, Division of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, BC, Canada
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Current understanding of allergic fungal rhinosinusitis and treatment implications. Curr Opin Otolaryngol Head Neck Surg 2014; 22:221-6. [DOI: 10.1097/moo.0000000000000043] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Doellman MS, Dion GR, Weitzel EK, Reyes EG. Immunotherapy in allergic fungal sinusitis: The controversy continues. A recent review of literature. ALLERGY & RHINOLOGY 2013; 4:e32-5. [PMID: 23772324 PMCID: PMC3679565 DOI: 10.2500/ar.2013.4.0045] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Allergic fungal sinusitis (AFS), also referred to as allergic fungal rhinosinusitis (AFRS), is a noninvasive, eosinophilic form of recurrent chronic allergic hypertrophic rhinosinusitis. AFS has distinct clinical, histopathological, and prognostic findings that differentiate it from other forms of sinusitis. The core pathogenesis and optimum treatment strategies remain debated. Concerns surround the use of immunotherapy for AFS because allergen-specific immunoglobulin G (IgG) induced by immunotherapy could theoretically incite a Gell and Coombs type III (complex mediated) reaction. Type I hypersensitivity is established by high serum levels of allergen-specific IgE to various fungal antigens and positive Bipolaris skin test results. Type III hypersensitivity is established by an IgG-mediated process defined by the presence of allergen-specific IgG that forms complexes with fungal antigen inducing an immunologic inflammatory response. These reveal the multiple immunologic pathways through which AFS can impact host responses. Recent literature establishing benefits of fungal immunotherapy and no evidence of type III–mediated reactions, severe local reactions, or delayed reactions, indicate that application of AFS desensitization is a reasonable therapeutic strategy for this difficult to manage entity. Our review should encourage further clinical acceptance of AFS desensitization because the existing literature on this subject shows benefits of fungal immunotherapy and no evidence of type III–mediated reactions, severe local reactions, or delayed reactions.
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Affiliation(s)
- Mary S Doellman
- Department of Otolaryngology Head and Neck Surgery, San Antonio Military Medical Center, San Antonio Military Medical Center, San Antonio, Texas, and
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The Role of Dendritic Cells and Immunotherapy in Allergic Fungal Rhinosinusitis. CURRENT OTORHINOLARYNGOLOGY REPORTS 2013. [DOI: 10.1007/s40136-013-0015-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Silva MP, Baroody FM. Allergic fungal rhinosinusitis. Ann Allergy Asthma Immunol 2013; 110:217-22. [PMID: 23535082 DOI: 10.1016/j.anai.2012.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Revised: 12/19/2012] [Accepted: 12/26/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Marianella Paz Silva
- Section of Otolaryngology-Head and Neck Surgery, The University of Chicago Medicine and the Pritzker School of Medicine, The University of Chicago, Chicago, Illinois 60637, USA
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Abstract
BACKGROUND Human exposure to fungal elements is inevitable, with normal respiration routinely depositing fungal hyphae within the nose and paranasal sinuses. Fungal species can cause sinonasal disease, with clinical outcomes ranging from mild symptoms to intracranial invasion and death. There has been much debate regarding the precise role fungal species play in sinonasal disease and optimal treatment strategies. METHODS A literature review of fungal diseases of the nose and sinuses was conducted. RESULTS Presentation, diagnosis, and current management strategies of each recognized form of fungal rhinosinusitis was reviewed. CONCLUSION Each form of fungal rhinosinusitis has a characteristic presentation and clinical course, with the immune status of the host playing a critical pathophysiological role. Accurate diagnosis and targeted treatment strategies are necessary to achieve optimal outcomes.
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Affiliation(s)
- Zachary M Soler
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Chang C, Gershwin ME, Thompson GR. Fungal disease of the nose and sinuses: an updated overview. Curr Allergy Asthma Rep 2013; 13:152-61. [PMID: 23135919 DOI: 10.1007/s11882-012-0320-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Fungal diseases of the nose and sinuses encompasses a diverse spectrum of disease. Clinical manifestations are largely dependent upon the immune status of the host, as, given the ubiquitous nature of these organisms, exposure is unavoidable. Asymptomatic colonization of the nasal passages by fungi warrants no treatment and is common, while allergic fungal rhinosinusitis is challenging and often requires a combined approach of surgical intervention, immunotherapy, and corticosteroid administration. A diagnosis requires a combination of IgE immune reactivity, eosinophilic infiltration, and fungi recovery. Similarly, invasive disease may present only after several months of slowly progressive disease, or in rapid and fulminant fashion in the appropriate host. A differentiation of these overlapping syndromes and the pathophysiologic processes at play, and recommended treatment algorithms, are the focus of this review.
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Affiliation(s)
- Christopher Chang
- Department of Pediatrics, Division of Allergy, Asthma, and Immunology, Nemours/A.I. Dupont Hospital for Children, Thomas Jefferson University, 1600 Rockland Road, Wilmington, DE, 19803, USA.
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Abstract
PURPOSE OF REVIEW Allergic fungal sinusitis (AFS) results from an immunoglobulin E (IgE)-mediated, eosinophil-predominant hypersensitivity reaction to extramucosal fungi within the paranasal sinuses. Although the pathogenesis of this noninvasive process is still not fully understood, there is new information. Recently, the use of allergen immunotherapy with fungal antigens as an adjunct in treatment of AFS has been evaluated. In this review, we summarize the experience in the published literature on the topic. RECENT FINDINGS There is evidence to suggest that allergen immunotherapy to fungal allergens may be effective in the treatment of symptoms of AFS and may decrease the rate of postoperative exacerbations and further operations. There is no evidence that this therapy induces immune complex disease. These studies pave the way for controlled trials of immunotherapy in patients with AFS. SUMMARY Allergen immunotherapy to fungi shows promise as a treatment to decrease the recurrence of AFS and should be considered a part of the treatment regimen. However, because the number of patients treated has been small and one study suggested that fungal immunotherapy administered before removal of fungal contents from the sinuses could worsen sinusitis, controlled studies are essential to moving forward.
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Won EJ, Shin JH, Lim SC, Shin MG, Suh SP, Ryang DW. Molecular identification of Schizophyllum commune as a cause of allergic fungal sinusitis. Ann Lab Med 2012; 32:375-9. [PMID: 22950076 PMCID: PMC3427828 DOI: 10.3343/alm.2012.32.5.375] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 05/15/2012] [Accepted: 07/19/2012] [Indexed: 11/19/2022] Open
Abstract
Schizophyllum commune, a basidiomycetous fungus, rarely causes disease in humans. We report a rare case of allergic fungal sinusitis caused by S. commune in a 14-yr-old girl. The patient presented with nasal obstruction and a purulent nasal discharge. Materials obtained during endoscopic surgery of the frontal recess revealed allergic mucin and a few fungal hyphae. A potato dextrose agar (PDA) culture from the allergic mucin yielded a rapidly growing white woolly mold. Although no distinctive features including hyphae bearing spicules or a clamp connection were present, the case isolate disclosed compatible mycological features including growth at 37℃, susceptibility to cycloheximide, and production of a tart and disagreeable smell. S. commune was confirmed by sequence analysis of the internal transcribed spacer region and D1/D2 regions of the 26S ribosomal DNA. We believe this is the first report of allergic fungal sinusitis caused by S. commune in Korea. Moreover, this report highlights the value of gene sequencing as an identification tool for non-sporulating isolates of S. commune.
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Affiliation(s)
- Eun Jeong Won
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
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Kameswaran M, Chopra H, Kanojia S, Janakiram TN, Vaid N, Soni A, Mohindroo NK, Charaya K, Shah N, Rai D, Nayar R, Rao CMS, Meghnadh KR, Patel HM, Sood S, Pandhi SC, Mann SBS. Allergic Fungal Rhinosinusitis. ACTA ACUST UNITED AC 2012. [DOI: 10.5005/jp-journals-10013-1124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
ABSTRACT
Allergic fungal rhinosinusitis (AFRS) has always remained a topic of discussion at all rhinology meets. Despite so much of literature available, the nature of this disease, its diagnosis, pathogenesis, classification and appropriate management continue to generate debate and controversy even after three decades of research and investigation. AFRS is an endemic disease in North and South India. In spite of this, there has been no optimal management protocol for this disease being followed in India yet. To overcome this, a national panel was conducted on AFRS at the ENT Surgical Update 2011, held at Postgraduate Institute of Medical Education and Research, Chandigarh with experts from all over the country so that a consensus can be achieved regarding the workup and management of AFRS.
How to cite this article
Gupta AK, Shah N, Kameswaran M, Rai D, Janakiram TN, Chopra H, Nayar R, Soni A, Mohindroo NK, Rao CMS, Bansal S, Meghnadh KR, Vaid N, Patel HM, Sood S, Kanojia S, Charaya K, Pandhi SC, Mann SBS. Allergic Fungal Rhinosinusitis. Clin Rhinol An Int J 2012;5(2): 72-86.
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Thompson GR, Patterson TF. Fungal disease of the nose and paranasal sinuses. J Allergy Clin Immunol 2011; 129:321-6. [PMID: 22206776 DOI: 10.1016/j.jaci.2011.11.039] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 11/22/2011] [Accepted: 11/23/2011] [Indexed: 12/01/2022]
Abstract
Fungal infections of the nose and paranasal sinuses represent a spectrum of diseases ranging from colonization to invasive rhinosinusitis. Clinical manifestations are largely dependent on the immune status of the host, and given the ubiquitous nature of these organisms, exposure is unavoidable. Noninvasive disease includes asymptomatic fungal colonization, fungus balls, and allergic fungal rhinosinusitis. Invasive disease includes indolent chronic rhinosinusitis, granulomatous fungal sinusitis, and acute fulminant fungal rhinosinusitis. A differentiation of these somewhat overlapping syndromes and the disparate treatment regimens required for effective management are the focus of this review.
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Affiliation(s)
- George R Thompson
- Department of Medical Microbiology and Immunology, Coccidioidomycosis Serology Laboratory, University of California-Davis, Davis, Calif 95616, USA.
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Panjabi C, Shah A. Allergic Aspergillus sinusitis and its association with allergic bronchopulmonary aspergillosis. Asia Pac Allergy 2011; 1:130-7. [PMID: 22053309 PMCID: PMC3206248 DOI: 10.5415/apallergy.2011.1.3.130] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 09/21/2011] [Indexed: 12/12/2022] Open
Abstract
Allergic Aspergillus sinusitis (AAS) is a three decade old clinicopathologic entity in which mucoid impaction akin to that of allergic bronchopulmonary aspergillosis (ABPA) occurs in the paranasal sinuses. Features such as radiographic evidence of pansinusitis, passage of nasal plugs and recurrent nasal polyposis in patients with an atopic background is suggestive of AAS. Histopathlogic confirmation from the inspissated mucus is a sine qua non for the diagnosis. Heterogeneous densities on computed tomography of the paranasal sinuses are caused by the 'allergic mucin' in the sinuses. Many patients give a history of having undergone multiple surgical procedures for symptomatic relief. The current approach to treatment appears to include an initial surgical debridement followed by postoperative oral corticosteroids for long durations. Although both ABPA and AAS are classified as Aspergillus-related hypersensitivity respiratory disorders, their co-occurrence appears to be an infrequently recognised phenomenon. This could perhaps be attributed to the fact that these two diseases are often treated by two different specialties. A high index of suspicion is required to establish the diagnoses of ABPA and AAS. All patients with asthma and/or rhinosinusitis along with sensitisation to Aspergillus antigens are at an increased risk of developing ABPA and/or AAS. ABPA must be excluded in all patients with AAS and vice versa. Early diagnosis and initiation of appropriate therapy could plausibly alter the course of the disease processes and prevent the possible development of long term sequelae.
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Affiliation(s)
- Chandramani Panjabi
- Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi 110 007, India
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Greenhaw B, deShazo RD, Arnold J, Wright L. Fungal immunotherapy in patients with allergic fungal sinusitis. Ann Allergy Asthma Immunol 2011; 107:432-6. [PMID: 22018615 DOI: 10.1016/j.anai.2011.05.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 05/10/2011] [Accepted: 05/13/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Allergic fungal sinusitis is a disease for which optimal treatment is unclear. Previous studies using fungal immunotherapy reported less recurrence after surgery. There has been concern that traditional high-dose immunotherapy could induce systemic hypersensitivity in patients with this condition. OBJECTIVE To determine the safety of high-dose subcutaneous fungal immunotherapy in patients with allergic fungal sinusitis. METHODS Safety of high-dose subcutaneous fungal immunotherapy was assessed in 14 patients from our clinic who met diagnostic criteria for allergic fungal sinusitis. Results were compared to a control group of 14 patients with chronic rhinosinusitis without allergic fungal sinusitis who received subcutaneous fungal immunotherapy. We also performed a literature search to identify all previous reports of subcutaneous fungal immunotherapy. RESULTS No differences between numbers of immediate local or large local reactions, delayed local reactions, or required dose adjustments were noted between patient and control groups. One patient from each group experienced a mild systemic urticarial reaction to immunotherapy. Similarly, there were no differences in complications in either group that also received immunotherapy with nonfungal allergens. No patient developed evidence of immune complex disease. Eight publications were identified for inclusion in our literature analysis, 7 of which used low-dose subcutaneous immunotherapy. None of these noted complications more serious than local reactions. CONCLUSION Our data demonstrate that subcutaneous fungal immunotherapy in patients with allergic fungal sinusitis is unlikely to cause adverse reactions other than those occurring with pollen immunotherapy. Clinical trials of high-dose, traditional immunotherapy with fungal allergens for efficacy may proceed in patients with allergic fungal sinusitis without undue concern.
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Affiliation(s)
- Bradley Greenhaw
- Department of Medicine, Division of Clinical Allergy and Immunology, University of Mississippi Medical Center, Jackson, USA
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Bozeman S, deShazo R, Stringer S, Wright L. Complications of allergic fungal sinusitis. Am J Med 2011; 124:359-68. [PMID: 21435427 DOI: 10.1016/j.amjmed.2010.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 11/18/2010] [Accepted: 12/06/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Allergic fungal sinusitis is a syndrome of chronic noninvasive fungal sinusitis that results in the accumulation of eosinophil-rich allergic mucin within the paranasal sinuses. This mucin may become an expansile mass leading to complications that have not been well characterized or classified. METHODS Inclusion criteria for this study required meeting previously published diagnostic criteria and complications greater than nasal polyps or sinusitis itself. Four patients from our cohort and 30 patients identified in a literature search formed the study group. RESULTS The majority of patients had pre-existing asthma or allergic rhinitis, or both, and 37% had nasal polyps before presentation. However, 27% had no previous history of rhinosinusitis or nasal polyposis. Complications of allergic fungal sinusitis fell into discrete categories: ophthalmic (n=13), sinobronchial allergic mycosis (n=9), bony erosion (n=8), cavernous venous thrombosis (n=3), and otic involvement (n=1). CONCLUSION Visual symptoms, proptosis, headaches, and increased nasal symptoms, especially in association with bony erosions on sinus computed tomography, suggest allergic fungal sinusitis and its complications in patients with chronic rhinosinusitis and nasal polyps. Patients with allergic fungal sinusitis may present with a complication of the disease as the first symptom. Complications may be categorized into groups that facilitate surveillance and early identification.
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Affiliation(s)
- Sarah Bozeman
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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Marple BF, Stankiewicz JA, Baroody FM, Chow JM, Conley DB, Corey JP, Ferguson BJ, Kern RC, Lusk RP, Naclerio RM, Orlandi RR, Parker MJ. Diagnosis and management of chronic rhinosinusitis in adults. Postgrad Med 2010; 121:121-39. [PMID: 19940423 DOI: 10.3810/pgm.2009.11.2081] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Chronic rhinosinusitis (CRS) is characterized by mucosal inflammation affecting both the nasal cavity and paranasal sinuses; its causes are potentially numerous, disparate, and frequently overlapping. The more common conditions that are associated with CRS are perennial allergic and nonallergic rhinitis, nasal polyps, and anatomical mechanical obstruction (septum/turbinate issues). Other less common etiologies include inflammation (eg, from superantigens), fungal sinusitis or bacterial sinusitis with or without associated biofilm formation, gastroesophageal reflux, smoke and other environmental exposures, immune deficiencies, genetics, and aspirin-exacerbated respiratory disease. A diagnosis of CRS is strongly suggested by a history of symptoms (eg, congestion and/or fullness; nasal obstruction, blockage, discharge, and/or purulence; discolored postnasal discharge; hyposmia/anosmia; facial pain and/or pressure) and their duration for > 3 months. A definitive diagnosis requires physical evidence of mucosal swelling or discharge appreciated during physical examination coupled with CT imaging if inflammation does not involve the middle meatus or ethmoid bulla. Multivariant causation makes the diagnosis of CRS and selection of treatment complex. Furthermore, various types of health care providers including ear, nose, and throat (ENT) specialists, allergists, primary care physicians, and pulmonologists treat CRS, and each is likely to have a different approach. A structured approach to the diagnosis and management of CRS can help streamline and standardize care no matter where patients present for evaluation and treatment. A 2008 Working Group on CRS in Adults, supported by the American Academy of Otolaryngic Allergy (AAOA), developed a series of algorithms for the differential diagnosis and treatment of CRS in adults, based on the evolving understanding of CRS as an inflammatory disease. The algorithms presented in this paper address an approach for all CRS patients as well as approaches for those with nasal polyps, edema observed on nasal endoscopy, purulence observed on nasal endoscopy, an abnormal history and physical examination, and an abnormal history and normal physical examination.
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Affiliation(s)
- Bradley F Marple
- UT-Southwestern Medical Center, Department of Otolaryngology-Head and Neck Surgery, Dallas, TX 75390-7208, USA.
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Localized immunoglobulin E expression in allergic rhinitis and nasal polyposis. Curr Opin Otolaryngol Head Neck Surg 2009; 17:216-22. [PMID: 19417663 DOI: 10.1097/moo.0b013e32832ad23d] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW This article reviews recent literature on local tissue identification of immunoglobulin E (IgE) in various sinonasal inflammatory conditions. Discussions of local IgE expression in allergic and nonallergic rhinitis, atopic and nonatopic sinonasal polyposis, and allergic fungal rhinosinusitis are included. RECENT FINDINGS Increased levels of IgE and positive reactivity on nasal allergen provocation tests have been demonstrated in nasal lavage fluid of patients with negative systemic allergy testing. In addition, elevated levels of Alternaria alternata-specific IgE have been identified in nasal polyp patients; this is hypothesized as a contributory factor in the development of nasal polyposis. Further evidence supports the role of local IgE to Staphylococcus aureus superantigens in atopic and nonatopic nasal polyposis. Finally, local IgE specific for a range of antigens has been identified in sinus and inferior turbinate tissue in patients with allergic fungal rhinosinusitis. SUMMARY Increased levels of IgE have been identified in sinonasal tissues in allergic and nonallergic rhinitis, atopic and nonatopic sinonasal polyposis, and allergic fungal rhinosinusitis. The ability to identify local tissue IgE in inflammatory sinonasal disease states may have significant diagnostic and therapeutic implications.
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Ahn CN, Wise SK, Lathers DM, Mulligan RM, Harvey RJ, Schlosser RJ. Local production of antigen-specific IgE in different anatomic subsites of allergic fungal rhinosinusitis patients. Otolaryngol Head Neck Surg 2009; 141:97-103. [DOI: 10.1016/j.otohns.2009.03.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Revised: 02/09/2009] [Accepted: 03/03/2009] [Indexed: 10/20/2022]
Abstract
Objective: Local production of antigen-specific IgE in allergic fungal rhinosinusitis (AFRS) is likely integral to the expression of allergy. This study examines if there are anatomic variations in local IgE expression or if variations among fungal and nonfungal IgE exist. Study Design: Cross-sectional study. Setting: Tertiary medical center. Subjects and Methods: Specimens from 11 AFRS, 8 chronic rhinosinusitis without nasal polyps (CRSsNP), and 9 control patients underwent immunohistochemical localization for IgE and evaluation for antigen-specific IgE by ImmunoCAP testing. Results: Inferior turbinate (IT) epithelium had greater IgE staining in AFRS than control ( P = 0.013) and CRSsNP ( P = 0.002). A significant difference was also found at the IT subepithelial level for AFRS compared with controls ( P = 0.001) and CRSsNP ( P < 0.001). Within AFRS, IgE staining was increased in the subepithelium compared to epithelium ( P = 0.003). ImmunoCAP analysis on IT tissue from AFRS and controls demonstrated increased antigen-specific IgE for 5 of 14 antigens ( P < 0.05) and total IgE ( P < 0.001). There were no significant anatomic differences between IT and sinus IgE staining. Conclusion: More fungal and nonfungal IgE is expressed in IT and sinus tissues of AFRS patients, as compared with control and CRSsNP patients.
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Affiliation(s)
- Chadwick N. Ahn
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Sarah K. Wise
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
- Department of Otolaryngology–Head and Neck Surgery, Emory University, Atlanta, GA
| | - Deanne M.R. Lathers
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Ryan M. Mulligan
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Richard J. Harvey
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Rodney J. Schlosser
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
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Fungus as the cause of chronic rhinosinusitis: the case remains unproven. Curr Opin Otolaryngol Head Neck Surg 2009; 17:43-9. [PMID: 19225305 DOI: 10.1097/moo.0b013e32831de91e] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW To review the literature on the role of fungi in chronic rhinosinusitis (CRS) pathogenesis and the effect of antifungal drug therapy and antifungal immunotherapy. RECENT FINDINGS This paper reviews the most recent articles investigating the role of fungi in CRS pathogenesis. In addition to possible aberrant innate and adaptive antifungal immune responses and fungus antihost effects, which all may explain disease development, the effect of antifungal drug therapy and antifungal immunotherapy is reviewed. SUMMARY Although fungi can be detected in the nose and paranasal sinuses of nearly all patients with CRS and are present in almost all healthy controls, various studies suggest that there may be mechanisms by which fungi exert an effect on sinus mucosa in susceptible individuals only. Future studies will have to clarify the role of fungi in CRS, which fungal organisms, if at all, may be pathogenic and what exactly characterizes the immunological response to fungi that potentially results in the development of disease. Presently, in the absence of convincing immunological data and evidence for clinical improvement of CRS upon therapy with antifungal agents, the case against the fungus remains unproven.
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Ebbens FA, Georgalas C, Fokkens WJ. The mold conundrum in chronic hyperplastic sinusitis. Curr Allergy Asthma Rep 2009; 9:114-20. [PMID: 19210900 DOI: 10.1007/s11882-009-0017-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The role of fungi in chronic rhinosinusitis (CRS) is not clear. Fungi can be detected in the nose and paranasal sinuses of virtually all CRS patients; however, they also appear to be present in healthy controls. Various theories attempt to explain the mechanisms by which fungi can exert an effect on sinus mucosa in susceptible individuals. Further studies are necessary to clarify the role of fungi in CRS, which fungal organisms (if any) are pathogenic, and what exactly characterizes the immunologic response to fungi that may result in the development of disease. However, in the absence of convincing immunologic data and evidence of clinical improvement of CRS after antifungal therapy, the case against the fungus remains unproven.
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Affiliation(s)
- Fenna A Ebbens
- Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, The Netherlands.
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Schubert MS. Allergic fungal sinusitis: pathophysiology, diagnosis and management. Med Mycol 2009; 47 Suppl 1:S324-30. [PMID: 19330659 DOI: 10.1080/13693780802314809] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Allergic fungal sinusitis (AFS) is a noninvasive form of fungal rhinosinusitis with an incidence of between 6 and 9% of all rhinosinusitis requiring surgery. Regional variation in incidence has been reported, with the southern and southwestern US particularly endemic. Patients with AFS commonly present with chronic rhinosinusitis with nasal polyps, inhalant atopy, elevated total serum immunoglobulin E (IgE), and sinus-obstructing inspissates of a characteristic extramucosal 'peanut buttery' visco-elastic eosinophil-rich material called 'allergic mucin' that contains sparse numbers of fungal hyphae. Sinus CT is always abnormal, showing findings of chronic rhinosinusitis that often include central areas of increased contrast ('hyperattenuation') within abnormal paranasal sinuses that represent the presence of fungal-containing allergic mucin. AFS has been found to be analogous in several ways to allergic bronchopulmonary aspergillosis (ABPA). Both are chronic inflammatory respiratory tract disorders that are driven by hypersensitivity responses to the presence of small numbers of extramucosal fungi found growing within airway-impacting allergic mucin. AFS allergic mucin typically cultures positive for either dematiaceous fungi such as Bipolaris spicifera or Curvularia lunata, or Aspergillus species such as A. fumigatus, A. flavus or A. niger. As with ABPA, patients have type I immediate hypersensitivity to the etiologic mold in AFS. Further, both AFS and ABPA have been found to have association with specific class II major histocompatibility alleles. Proper diagnosis of AFS and differentiation from the other forms of both noninvasive and invasive fungal rhinosinusitis requires strict adherence to published diagnostic criteria. Medical treatment of AFS has been modeled to an extent after treatment approaches for ABPA that includes the use of postoperative oral corticosteroids and aggressive antiallergic inflammation therapy. The use of follow-up measurements of total serum IgE during treatment of both AFS and ABPA patients can help to monitor disease activity. Future AFS research will lead to further insights into pathogenesis, improved treatments, and ultimately decreases in surgical recurrence rates for this highly recurrent hypertrophic rhinosinusitis disorder.
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Wise SK, Ahn CN, Lathers DM, Mulligan RM, Schlosser RJ. Antigen-specific IgE in Sinus Mucosa of Allergic Fungal Rhinosinusitis Patients. ACTA ACUST UNITED AC 2008; 22:451-6. [DOI: 10.2500/ajr.2008.22.3227] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Local tissue production of antigen-specific immunoglobulin E (IgE) has been shown in patients with allergic rhinitis and in patients with chronic rhinosinusitis (CRS) with nasal polyps. In allergic fungal rhinosinusitis (AFRS), specific IgE has been established in nasal lavage fluid and eosinophilic mucin. In this study, local production of antigen-specific IgE within sinus mucosa of AFRS patients was evaluated. Methods Sinus mucosa homogenates from 11 AFRS patients, 8 patients with CRS without nasal polyps (CRSsNP), and 9 nonrhinosinusitis control patients were assessed for IgE localization by immunohistochemistry. AFRS and control tissue homogenates were also evaluated for antigen-specific IgE to 14 common antigens by ImmunoCAP testing (Phadia AB, Portage, MI). Results There was a significant increase in IgE staining in AFRS sinus epithelium and subepithelium compared with controls and with patients with CRSsNP (p ≤ 0.012 for all group differences). AFRS patients showed increased IgE staining in the subepithelium when compared with epithelium (p < 0.001). AFRS sinus tissue had significantly more IgE measured by ImmunoCAP when compared with control sinus tissue for 7 of 14 specific antigens (p < 0.05) and for total IgE (p = 0.004). Antigens with a significant difference on ImmunoCAP included Cladosporium, Aspergillus, Timothy grass, red maple, cockroach, ragweed, and cocklebur. Conclusion AFRS patients showed significantly more IgE in sinus mucosa tissue specimens, with increased IgE in subepithelial sites when compared with epithelium. The increased expression of antigen-specific IgE is not limited to fungal antigens. These findings support the role of type I hypersensitivity and local manifestations of allergy in AFRS patients.
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Affiliation(s)
- Sarah K. Wise
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Suite 1130, P.O. Box 250550, Charleston, South Carolina
- Department of Otolaryngology–Head and Neck Surgery, Emory University, 1365A Clifton Road NE, Suite A2300, Atlanta, Georgia
| | - Chadwick N. Ahn
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Suite 1130, P.O. Box 250550, Charleston, South Carolina
| | - Deanne M.R. Lathers
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Suite 1130, P.O. Box 250550, Charleston, South Carolina
- Ralph H. Johnson VAMC, Research Service, 109 Bee Street, Charleston, South Carolina
| | - Ryan M. Mulligan
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Suite 1130, P.O. Box 250550, Charleston, South Carolina
| | - Rodney J. Schlosser
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Suite 1130, P.O. Box 250550, Charleston, South Carolina
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Ebbens FA, Fokkens WJ. The mold conundrum in chronic rhinosinusitis: where do we stand today? Curr Allergy Asthma Rep 2008; 8:93-101. [PMID: 18417050 DOI: 10.1007/s11882-008-0018-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Chronic rhinosinusitis (CRS) is an inflammatory disorder affecting the nose and paranasal sinuses. Although bacteria have long been implicated as pathogens in most forms of CRS, fungi may be responsible for some forms. Several recent studies demonstrated that, under optimal conditions, fungi can be identified in the nose and paranasal sinuses of nearly every individual (including all CRS patients). An aberrant immune response to these ubiquitous fungi has been suggested to explain the development of CRS in some individuals. Several mechanisms requiring additional research, including adequate controls, have been proposed and are reviewed in this article. Although preliminary trials suggested that CRS signs and symptoms improve upon treatment with topical and oral antifungal agents, several double-blind, placebo-controlled trials demonstrated the contrary. In the absence of convincing immunologic data and evidence of clinical improvement upon therapy with antifungal agents, the case against fungi remains unproven.
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Affiliation(s)
- Fenna A Ebbens
- Department of Otorhinolaryngology, Head and Neck Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Advances in management of paranasal sinus aspergillosis. The Journal of Laryngology & Otology 2007; 122:331-5. [DOI: 10.1017/s0022215107000722] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractSurgery remains the treatment of choice for mycetoma of the paranasal sinuses. Itraconazole has a useful role in reducing both the amount of surgery required and the amount of peri-operative bleeding in allergic aspergillosis, and continuing its use post-operatively for six weeks appears to reduce the recurrence rate (although a case–control study is required to validate this observation). In chronic invasive aspergillosis, itraconazole alone appears to be curative, although liver function tests should be monitored and other interactions considered. Imaging is required to monitor resolution; remineralisation occurs after approximately six months. In fulminant aspergillosis, radical surgery and amphotericin B continue to be the treatments of choice. This review discusses the management of aspergillosis of the paranasal sinuses, and in particular the role of itraconazole antifungal therapy.
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Gupta AK, Bansal S, Gupta A, Mathur N. Visual loss in the setting of allergic fungal sinusitis: pathophysiology and outcome. The Journal of Laryngology & Otology 2007; 121:1055-9. [PMID: 17319994 DOI: 10.1017/s0022215107006226] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:To hypothesise the probable pathophysiological mechanism responsible for visual loss in allergic fungal sinusitis, other than direct compression.Design:Retrospective, non-randomised case series. Out of 274 cases of allergic fungal sinusitis, four cases with sudden visual loss were enrolled into the study. The fourth case had visual loss on the contralateral side to bony erosion of the lateral wall of the sphenoid sinus.Interventions:All four cases were evaluated with fungal smear, immunoglobulin (Ig) E titres, visual evoked potentials, non-contrast computed tomography and magnetic resonance imaging of the paranasal sinuses, and fundus examination. They then underwent endoscopic sinus debridement followed by intravenous methylprednisolone.Outcome measures:Improvement in vision.Results:All four cases experienced an improvement in vision: full recovery in three cases and partial improvement in one case.Conclusion:In view of the operative, radiological and laboratory findings for case four, with the suggestion of a hyperimmune response to fungal antigens (in the form of raised IgE titre and positive fungal serology), we suggest that a local immunological reaction to fungal antigens might be responsible for the observed visual loss in cases of allergic fungal sinusitis, in addition to mechanical compression of the optic nerve.
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Affiliation(s)
- A K Gupta
- Department of Otolaryngology, Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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46
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Schubert MS. Allergic fungal sinusitis. Clin Rev Allergy Immunol 2006; 30:205-16. [PMID: 16785591 DOI: 10.1385/criai:30:3:205] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 11/11/2022]
Abstract
Many common chronic inflammatory rhinosinusitis conditions (hypertrophic sinus disease [HSD]) have the histopathological profile of allergic or asthmatic inflammation. Allergic fungal sinusitis (AFS) is both a type of noninvasive fungal rhinosinusitis and a type of HSD. AFS has clinicopathological features that make it similar, but not identical, to allergic bronchopulmonary aspergillosis (ABPA). Allergic mucin is a defined pathological entity occurring in ABPA, AFS, and in the HSD "eosinophilic mucin rhinosinusitis (EMRS)." Diagnosis of AFS requires a careful review of surgical reports, histopathology, and culture results. Treatment includes surgery and aggressive postoperative medical management of allergic inflammatory disease. Prognosis is good with integrated medical-surgical follow-up, but recurrence remains problematic. The association of ABPA, AFS, and HSD with class II genes of the major histocompatibility complex places the initiation of these inflammatory diseases within the context of antigen presentation and the acquired immune response. Pathological immunomanipulation of this response by local microbial superantigens may be a common mechanism for disease pathogenesis. Future research into the molecular biology of these related conditions may offer insight into the pathogenesis of other chronic inflammatory diseases.
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47
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Abstract
Many common chronic inflammatory rhinosinusitis conditions (hypertrophic sinus disease [HSD]) have the histopathological profile of allergic or asthmatic inflammation. Allergic fungal sinusitis (AFS) is both a type of noninvasive fungal rhinosinusitis and a type of HSD. AFS has clinicopathological features that make it similar, but not identical, to allergic bronchopulmonary aspergillosis (ABPA). Allergic mucin is a defined pathological entity occurring in ABPA, AFS, and in the HSD "eosinophilic mucin rhinosinusitis (EMRS)." Diagnosis of AFS requires a careful review of surgical reports, histopathology, and culture results. Treatment includes surgery and aggressive postoperative medical management of allergic inflammatory disease. Prognosis is good with integrated medical-surgical follow-up, but recurrence remains problematic. The association of ABPA, AFS, and HSD with class II genes of the major histocompatibility complex places the initiation of these inflammatory diseases within the context of antigen presentation and the acquired immune response. Pathological immunomanipulation of this response by local microbial superantigens may be a common mechanism for disease pathogenesis. Future research into the molecular biology of these related conditions may offer insight into the pathogenesis of other chronic inflammatory diseases.
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48
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Jackson LL, Kountakis SE. Classification and management of rhinosinusitis and its complications. Otolaryngol Clin North Am 2006; 38:1143-53. [PMID: 16326174 DOI: 10.1016/j.otc.2005.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A stepwise evaluation of patients who have CRS allows a management approach that is tailored to each individual patient and to the specific type of disease.
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Affiliation(s)
- Lana L Jackson
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia, 1120 15th Street, Augusta, GA 30912, USA
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Marple BF. Allergic fungal rhinosinusitis: A review of clinical manifestations and current treatment strategies. Med Mycol 2006; 44:S277-S284. [DOI: 10.1080/13693780600778650] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Abstract
Collective clinical and bench observations of the past 25 years have expanded interest in the role that fungi may play in developing and perpetuating inflammatory disease of the respiratory tract. As with any new concept, controversy regarding such a process has emerged, but it has served to stimulate increased interest and further study. Review of the current literature appears to offer strong evidence to support both allergic and nonallergic forms of noninvasive fungal inflammation. It remains to be seen whether or these forms of inflammation are inter-related or independent of one another. As investigation focusing upon these new concepts continues, it should lead to better understanding of chronic inflammatory disease of the respiratory tracts.
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Affiliation(s)
- Amber Luong
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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